鼓室硬化症的手术治疗(附136例病例分析)

Surgical treatment of tympanosclerosis: a retrospective analyses of 136 cases

目的介绍我们对鼓室硬化症的手术方法,分析不同手术治疗方法与效果的关系。方法136例鼓室硬化症病人按Wielinga等的分类方法分成四型:Ⅰ型41例,Ⅱ型49例,Ⅲ型36例,Ⅳ型10例。鼓膜完整者56例,鼓膜干性穿孔者54例,鼓膜穿孔伴耳流脓者26例。手术前常规进行纯音测听和中耳分析,得出各型不同情况下的气骨导差均值。硬化灶的手术处理分为:(1)对Ⅰ型病例适度剔除鼓膜上的硬化灶;(2)对Ⅱ型病例多数采用单纯剔除硬化灶+撼动听骨链的方法,少数病人切除砧骨和锤骨头,用人工听骨重建听骨链;(3)Ⅲ型和Ⅳ型病例,一律将砧骨和锤骨头切除,清除上鼓室病灶,采用PORP或TORP重建听骨链。对镫骨底板不活动的病例,采用特氟隆活塞型人工镫骨重建听骨连接;对于镫骨底板不活动而炎症尚未控制者,行二期镫骨小窗手术。结果由于术后流脓以及听骨赝复物脱出等原因,总失败率为10.29%。剔除失败病例后,术后1年的纯音测听结果与术前比较有明显改善:I型病例气骨导差平均改善13.75dB,Ⅱ型平均改善22.93dB,Ⅲ型和Ⅳ型平均改善29.14dB,所有病例听力均恢复到实用水平。结论手术处理是治疗鼓室硬化症的主要手段,手术方式则根据病变累及的范围和程度决定。根据我们的资料,对Ⅱ型以上的鼓室硬化症均可采用听骨赝复物重建听骨链,且采用人工听骨赝复的远期效果较好。

Objective To presente our surgical protocols for tympanosclerosis and to evaluate their efficacy. Methods One hundred and thirty-six cases with tympanosclerosis were grouped into four types, based on Wielinga＇s categorization, type Ⅰ in 41, type Ⅱin 49, type Ⅲ in 36 and type Ⅳ in 10 cases. Among them, the tympanic membrane in 56 cases was intact, tympanic membrane perforation with or without infection was seen in 26 and 54 cases, respctively. Before any surgeries, all the patients underwent pure-tone threshold testing and midlle ear analysis. According to different situations, the surgical treatment options were as follows： （1） For typeⅠ , the sclerosis focus was reasonably eliminated; （2） For most type Ⅱ, the sclerosis focus was eliminated and the ossicular chain, mobilized. Sometimes the ossicular chain was removed and rebuilt with artificial ossicular replacement prosthesis; （3） For type Ⅲ and type Ⅳ, the incus and malleus and the sclerosis focus of epitympanum were eliminated and the ossicular chain was rebuilt by PORP or TORP. For the patients whose stapes foot plate was fixed, the ossicular chain was reconstructed using the artificial Teflon pistontype stapes. For the patients whose stapes foot plate was fixed and the inflammation was not under control, a second-stage operation was advocated. Results Owning to suppuration after operation, ossicular replacement prosthesis exclusion and some other reasons, the total failure rate was 10.29%. Exception of the failure cases, the results of pure-tone threshold testing one year after operation showed a significant improvement, compared with that before operation. The means ABG improvement in type Ⅰ, type Ⅱ and combined type Ⅲ/type Ⅳpatients was 13.75 dB, 22.93 dB and 29.14 dB, respectively. All the patients resumed the practical hearing level. Conclusion Surgery operation is the main method for tympanosclerosis. The operation should be adapted to different areas and degrees of the pathological changes. According to our results, for the Type Ⅱ and more serious patients, ossicular replacement prosthesis can be used to reconstruct the ossicular chain, besides, the-long-term effect by using artificial ossicular replacement prosthesis was better than that by using autograft of ossicles.